Adherence to surviving sepsis guidelines among pediatric intensivists. A national survey.

OBJECTIVES: To assess the compliance with the 2006 American College of Critical Care-Pediatric Advanced Life Support (ACCM-PALS) guidelines for sepsis management, and the 2012 surviving sepsis campaign (SSC), for the management of pediatric patients with sepsis and to identify the main barriers to adherence to these guidelines. Methods: In November 2015, a prospective cohort study in which a web based electronic survey using a case scenario to explore the usual management of a child with severe sepsis was designed and sent to all consultant pediatric intensivists practicing in Kingdom of Saudi Arabia (KSA). Adherences to 2012 SSC guidelines and to 4 algorithmic time-specific goals outlined in the ACCM-PALS guidelines were measured. Results: Sixty-one (76%) of 80 consultant pediatric intensivists working in KSA responded to the survey. Of the 61 respondents, 94% reported administering antibiotics within one hour of the child presentation, 98% reported starting resuscitation by giving fluid boluses, 93% reported starting vasopressor if the patient remained hypotensive despite fluid resuscitation, and 86% reported they would start hydrocortisone in case of catecholamine refractory shock. In total, 80% of the intensivists reported full adherence to all of the 4 components in the ACCM-PALS bundle; 50% reported that the absence of a locally written protocol was the main barrier to adherence to the SSC guidelines. Conclusion: Pediatric intensivists reported good adherence to the 2006 ACCM-PALS guidelines and 2012 SSC guidelines with some variability in interpretation of the recommendations. The absence of a written protocol was the main reported barrier to adherence to these guidelines.

Septic pulmonary embolism secondary to Staphylococcus aureus septic thrombophlebitis in a pediatric patient.

We present the clinical course of an 11-year-old child with septic pulmonary embolism secondary to community acquired methicillin-resistant Staphylococcus aureus (MRSA) septic deep venous thrombosis. The aim is to emphasize the non-specific symptoms of septic pulmonary embolism in pediatrics, the frequent association with septic deep venous thrombosis and osteomyelitis, and to highlight that MRSA is the most frequently isolated organism. Pediatricians should consider septic pulmonary embolism in cases of septic deep venous thrombosis even in the absence of respiratory symptoms. The initial antibiotic management should include glycopeptides, as community acquired MRSA is increasingly the isolated organism in this disorder.

Overview of bronchiolitis.

Respiratory syncytial virus RSV, a nonsegmented, single stranded ribonucleic acid virus, infects one-half of all infants within the first year of life. Respiratory syncytial virus possesses pathogenetic qualities that may be attributed to the interplay of viral and host-specific factors including virus strains of different virulence, size of the inoculum, family history of asthma or airway hyper-reactivity and immunologic anomalies of the host. Inflammatory cell recruitment and activation occur in response to RSV infection of epithelial cells. Epithelial cells initiate the inflammatory response to RSV by elaborating a wide variety of cytokines and chemokines that trigger further inflammatory responses. Treatment of RSV in infants with bronchiolitis is complicated due to the multifactorial nature of this infection. Treatment of RSV bronchiolitis rests primarily on supportive care with oxygen and fluid management. Other therapies commonly used include bronchodilators, corticosteroids and ribavirin, where considered appropriate. Although oxygen administration and judicious fluid replacement are the only interventions proved to be of reliable benefit to infants with bronchiolitis, newer studies support a role for adjunctive therapies aimed at relieving airway obstruction, especially when administered very early in the course of the illness or given to infants with more severe disease.

Can we reduce mortality in sepsis?

Considerable progress has been made over the last 2 decades in diagnosing and treating sepsis. Although the mortality rate is beginning to decline with the development of new therapeutic interventions, it still remains unacceptably high. Five such interventions are discussed in this review article to provide guidance for intensivists on the integration and implementation of new interventions into the intensive care unit. They were shown in randomized, controlled trials to reduce mortality by limiting the tidal volume in acute lung injury or acute respiratory distress syndrome, the early goal directed therapy, the use of recombinant human activated protein C, the use of moderate doses of steroids and the tight control of blood sugar. Each new intervention has a role in the management of sepsis, however they are not mutually exclusive. This article provides guidelines on optimal patient selection and timing for each intervention and provides advice on how to integrate new therapies in intensive care practice so that mortality rates can be reduced.

Pediatric living-related liver transplantation in Saudi Arabia.

OBJECTIVE: The purpose of this paper is to report our experience of the first 29 consecutive living-related liver transplants in pediatric recipients and to demonstrate the feasibility of living-related liver transplantation in the Arab World. The first living-related liver transplantation in the Kingdom of Saudi Arabia was performed in November 1998 by Bassas et al following an appropriate period of multi-disciplinary preparation. METHODS: This study was carried out at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia, during the period November 1998 through to October 2001. A review of the data of the transplanted children and adult donors was carried out. The data recorded for recipients included age, sex, patient's weight, preoperative diagnosis, intraoperative surgical complications, graft size and weight, medical and surgical postoperative complications, immunosuppression, rejection and overall survival rate. Data recorded for the donors included age, sex and any postoperative complications. RESULTS: The most frequent indication for living-related liver transplantation in our series was metabolic liver disease. Post-operative complications included biliary leaks in 10% (N=3), vascular occlusion in 13% (N=4), acute cellular rejection in 38% (N=11), positive cytomegalovirus PP65 antigen in 38% (N=11), wound infection in 3.4% (N=one), and systemic infections in 14% (N=4). One urgent retransplantation was necessary due to thrombosis of the hepatic artery. Patient and graft survival rates are 96% and 93%. One patient, treated for acute liver failure, died 2 months post-transplant. CONCLUSION: Our experience has shown pediatric living-related liver transplantation to be a success whilst alleviating the need for sending Saudi patients overseas for treatment and providing a solution to organ shortages for pediatric patients. In general, this endeavor has broadened the spectrum of our experience in surgery, anesthetics, intensive care and pediatrics.

Living-related liver transplantation for Crigler-Najjar syndrome in Saudi Arabia.

OBJECTIVE: To analyse the outcome of six children with Crigler-Najjar syndrome type I (CNS-I) and report the first three living-related liver transplants for this syndrome in Saudi Arabia and the Middle East. SETTINGS: To review the medical records of six children suffering from CNS-I, three of whom underwent living-related liver transplantation (LRLT) between 22 November 1998 and January 2001. MAIN RESULTS: Living-related liver transplantation was performed in three children with a pre-transplant unconjugated bilirubin level of 362, 381 and 502 micromol/L, respectively, despite daily phototherapy of >or= 12 h. Two of the transplanted children developed acute hepatocellular rejection, which was successfully treated with methylprednisolone pulse therapy. One tested cytomegalovirus positive (using the PP65 method), but showed no signs of clinical infection and was treated with ganciclovir. One patient had a biliary leak at the cut surface of the graft which was surgically repaired. Post-operative bilirubin levels returned to normal in all three transplanted children and no further phototherapy was required. One patient, who was not transplanted but received phototherapy, developed severe neurological damage prior to the start of our living-related liver transplant programme with a bilirubin level of 450 micromol/L, her sister is still awaiting transplantation. A 14-yr-old child with a bilirubin level of 420 micromol/L is presently undergoing phototherapy whilst awaiting orthotopic liver transplantation because of the lack of a suitable living-related donor. Six siblings of the six children in our series were reported dead by the families. CONCLUSION: Crigler-Najjar syndrome type I is a relatively common disease in Saudi Arabia for which LRLT is a curative treatment when performed at an early age before the development of kernicterus and neurological deficiency. In countries where there is a severe shortage of cadaveric organs, as is the case in Saudi Arabia, LRLT is the optimum treatment modality for this syndrome.